Department of General Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Neurocrit Care. 2021 Aug;35(1):87-102. doi: 10.1007/s12028-020-01143-7. Epub 2020 Nov 18.
Elevated intracranial pressure due to cerebral edema is associated with very poor survival in patients with acute liver failure (ALF). Placing an intracranial pressure monitor (ICPm) aids in management of intracranial hypertension, but is associated with potentially fatal hemorrhagic complications related to the severe coagulopathy associated with ALF.
An institutional Acute Liver Failure Clinical Protocol (ALF-CP) was created to correct ALF coagulopathy prior to placing parenchymal ICP monitoring bolts. We aimed to investigate the frequency, severity, and clinical significance of hemorrhagic complications associated with ICPm bolt placement in the setting of an ALF-CP. All assessed patients were managed with the ALF-CP and had rigorous radiologic follow-up allowing assessment of the occurrence and chronology of hemorrhagic complications. We also aimed to compare our outcomes to other studies that were identified through a comprehensive review of the literature.
Fourteen ALF patients were included in our analysis. There was no symptomatic hemorrhage after ICP monitor placement though four patients were found to have minor intraparenchymal asymptomatic hemorrhages after liver transplant when the ICP monitor had been removed, making the rate of radiographically identified clinically asymptomatic hemorrhage 28.6%. These results compare favorably to those found in a comprehensive review of the literature which revealed rates as high as 17.5% for symptomatic hemorrhages and 30.4% for asymptomatic hemorrhage.
This study suggests that an intraparenchymal ICPm can be placed safely in tertiary referral centers which utilize a protocol such as the ALF-CP that aggressively corrects coagulopathy. The ALF-CP led to advantageous outcomes for ICPm placement with a 0% rate of symptomatic and low rate of asymptomatic hemorrhagic complications, which compares well to results reported in other series. A strict ICPm placement protocol in this setting facilitates management of ALF patients with cerebral edema during the wait time to transplantation or spontaneous recovery.
脑水肿导致颅内压升高与急性肝衰竭（ALF）患者的生存预后极差相关。颅内压监测（ICPm）有助于颅内高压的管理，但与与 ALF 相关的严重凝血功能障碍相关的潜在致命性出血并发症有关。
创建了机构性急性肝衰竭临床方案（ALF-CP），以在放置实质 ICP 监测螺栓之前纠正 ALF 凝血功能障碍。我们旨在研究在 ALF-CP 背景下，ICPm 螺栓放置相关的出血并发症的频率、严重程度和临床意义。所有评估的患者均接受 ALF-CP 治疗，并进行严格的影像学随访，以评估出血并发症的发生和时间顺序。我们还旨在将我们的结果与通过全面文献回顾确定的其他研究进行比较。
我们的分析纳入了 14 名 ALF 患者。尽管在移除 ICP 监测器后，有 4 名患者在进行肝移植时发现存在轻微的脑实质内无症状性出血，但在 ICP 监测器放置后没有出现症状性出血。因此，影像学识别的临床无症状性出血率为 28.6%。这些结果与文献综述中发现的结果相比具有优势，其中症状性出血率高达 17.5%，无症状性出血率为 30.4%。
这项研究表明，在积极纠正凝血功能障碍的三级转诊中心，如使用 ALF-CP 等方案，可以安全地放置脑实质内 ICPm。ALF-CP 导致 ICPm 放置的有利结果，症状性和无症状性出血并发症的发生率均为 0%，与其他系列报道的结果相比表现良好。在这种情况下，严格的 ICPm 放置方案有助于管理等待肝移植或自发性恢复期间的脑水肿 ALF 患者。
